Friday, December 15, 2017

Winter Weather, Injuries and EMS Documentation for Billing

‘Tis the Season!

Here in the Northeast we experienced the first significant snowfall of the year. Additionally, last week saw an unprecedented ice and snow event roll through even the Deep South.

Winter Weather, Injuries and EMS Documentation for Billing
Of course, all of us in EMS know that snow and ice bring falls. Bones are ripe for breaking when your patients slip and fall in the midst of adverse weather events. This time of year brings to mind that it’s time to review some tips for documenting these events in the Patient Care Reports (PCRs) we prepare to document the ambulance run.

Think Coding

When preparing your PCR following a weather-related incident, think coding.

ICD-10 diagnosis coding has ushered in a level of specifics that requires more detail to be documented about our EMS incidents. The codes that we use in the EMS billing office are organized by several criteria including anatomical location, injury categories and mechanism plus taking into consideration affected body systems.

Then there are the finer details such as the relational aspects of laterality. 

ICD-10 has made the entire process more intense and requires a level of field documentation that is more detailed than ever.


You are dispatched to a fall victim located outside his residence. The dispatcher relays that you patient is an elderly male patient who has fallen outside and has a possible leg fracture. Your coverage area is in the middle of a present snow storm and as you make your way to the scene, the driving is fairly hazardous and slippery.

All ground surfaces are covered with a dangerous layer of ice.

You arrive on the scene to find your patient lying on the sidewalk. He had been trying to shovel the snow and slipped landing with his left leg underneath the weight of his body. Your initial assessment finds the patient complaining of considerable pain (a “10”) in the lower part of his left lower extremity just below the knee area.

You note swelling and bruising has already occurred and there is notable angulation in the distal portion of the tib/fib area.

Of course, you take all the necessary precautions, applying a splint to the extremity and move the patient to a long board having applied a c-collar before moving the patient.

Once upon a time…

Once upon a time, an EMS provider could document this scenario a bit more broadly. That documentation would have probably included a mention about the fact that the patient fell, was alert and oriented upon patient access and that the suspected injury involved a possible leg fracture.

We’re sure you did a good job painting the overall picture then. But, would the documentation of yesterday measure up to today’s requirements? 

Probably not.


The ICD-10 reality that we live in today, requires so much more detail to be recorded in the PCR. Plus, every one of you wants to keep your billing office happy- right?

Let’s explore what we need to bring in from the field by way of documentation to meet the requirements of today.

Location, Location, Location…

Focusing on the injury itself, we must now remember we need to include not just that it’s a leg but what anatomical part of the leg injury.

So our new mindset will require us to document something to the effect…
“Upon palpation of the affected lower left extremity, the patient was found to have considerable stabbing pain which she rated as a “10” on a 1-10 scale in the distal area of the tibia/fibula section of the extremity just below the knee area. Upon examination, we found the area to be slightly angulated and asymmetrical with the same area of the right lower extremity. There was notable swelling and bruising to indicate that the traumatic injury most likely involved the potential for fracture in the general area described.”
Notice with just a few lines in our subjective narrative, we were able to adequately pinpoint the exact area of the injury, the suspected anatomical location of the injury, the pain level with a numeric qualification and a quality description of the pain in the patient’s own words along with the suspected type of blunt force trauma the patient experienced as a result of her fall from a standing position.

Sans this kind of focused specificity in your documentation, the billing office will potentially be unable to pick the appropriate ICD-10 code.

Other things to consider…

Of course, our example focused on an extremity injury but there are tons of other scenarios that can happen when bad weather strikes ranging from falls, exposure incidents to motor vehicle accident injuries. Consider the potential for injury from winter recreation activities like skiing or ice skating.

Now we’re thinking not only extremity injuries but also head injuries, chest and abdominal trauma ushering all kinds of injuries that go beyond fractures and may include circulatory and/or respiratory compromise.

Are you prepared to document these incidents with the correct level of detail? If not, time to brush up and get ready because the Winter of 2017-2018 is here!

Friday, December 8, 2017

“Dear Santa”…a letter from the Billing Office

We intercepted…

It’s one of those things that happens.

“Dear Santa”…a letter from the Billing Office

A piece of mail floated into our billing office mailbox just this week and behold it was a note to Santa from a billing office far, far away. Good ol’ Uncle Sam’s delivery guys saw billing on it and popped it in our box….zip goes the opener and much to our surprise we read this little plea from the gal in the billing office to the jolly old elf at the North Pole.

Contents as follows.

“Dear Santa…I’ve been a VERY good girl this year…”

Dear Santa, 

It’s (name redacted to protect her PHI)!

I hope you and Mrs. C are doing very well. How has your year-long rest been? Are the elves pumping out lots of toys for good little girls and boys?

You must be as busy as I am this time of year! Of course, my world consists of endless documentation, lots of phone calls to insurance payers and of course the normal day of posting, following-up on denials and working with the flow of dollars that come in for our local ambulance.

Does the North Pole have an ambulance service? If they do, who does the billing?


Anyway, enough with all of that.

I’m writing to you with my Christmas list for this year. We ambulance billers must look out for the guys and gals on the street who help out the people in our community and so I’m asking you to intervene this year big time.

There’s just never enough money, it seems. We really need you to put the fear of God into the guys down there in Washington to cough up more bucks (not the reindeer buck…the money kind- you know….cold, hard cash)?

Those guys in Washington are dragging their feet about approving the bonus payments for Medicare. If you can, will you please threaten all of them with lumps of coal in their stocking (clean coal, of course….don’t want the North Pole to melt with all those nasty emissions you know.)

Congress needs to pass the extension of the bonus payments before they break for Christmas and if they don’t then you need to really give them the business. I know that they’ll listen to you because they rarely listen to us.


While you’re laying that finger aside of your nose and just before up the chimney you “rose”, can you also put a bug in their ear about designating us as providers instead of suppliers?

That way, our people in the field can help out those that need some services in their home but don’t need to be transported to a hospital by ambulance…and yet, when we do help them we can still be paid.

It’s really high time that they make this happen.

You know….like when you eat too many cookies from each house you visit on Christmas Eve and your diabetes kicks in and you need someone to help you maintain a safe dextrose level? Your local EMS could visit and take the stress off of poor Mrs. Claus…and we’d get paid for helping you monitor your levels.

That would be just swell.


Sorry for the long letter, but before I close out.

I’m going to ask that you bring a special extra something for all those really good big boys and girls that do this EMS thing every day.

I know that you don’t see these folks in action all year long because the North Pole is a LOOOONNNNGGGG way away, but I watch them do their thing every day from my office window and, frankly, I’m in awe of what they do.

Santa…they are selfless and giving and caring and they save so many lives. But so many of them are working so hard and many of them could be doing so many other things...but they do this EMS thing because they love what they do.

And that, Santa, is my Christmas wish list. I don’t need a whole lot- maybe a new computer and patience to put up with those insurance guys. Other than that I’m good.

So, give Mrs. C a big hug and kiss from me. Don’t eat too many cookies or drink too much milk (or whatever you drink…no DUI’s on the sleigh!!) And, of course, fly around carefully even though there is probably an ICD-10 code for “accident involving reindeer and sleighs”- we don’t wanna use it now- do we??

Merry Christmas and Happy New Year…Love…

Your Favorite Biller

Friday, December 1, 2017

Dissecting the Ambulance Inflation Factor for 2018

AIF Announced

The Centers for Medicare and Medicaid Services (CMS) announced the Ambulance Inflation Factor (AIF) for Calendar Year 2018 (CY 2018). Once again this year, the AIF is positive so let’s take a look at how we’ve arrived at this adjustment.

Dissecting the Ambulance Inflation Factor for 2018


Two factors are put together to come up with the annual adjustment.

The first element contributing to the calculations is the Consumer Price Index for all urban consumers (CPI-U) for the 12-month period ending with June of the previous year. Once that value is recorded then a productivity adjustment equal to the 10-year moving average of changes in economy-wide private non-farm business multi-factor productivity beginning January 1, 2011 is subtracted as an adjustment.
The end-product of this formula combining those two factors is the percentage that is referred to as the AIF as represented by the formula displayed above.

The CPI-U for 2018 has been calculated at 1.6% while the MFP is checking in at 0.5%. Therefore the resulting AIF will be 1.1% for CY 2018.
1.6% - 0.5% = 1.1%
Let’s break down each element to learn more about where these factors are derived.


The CPI-U or the Consumer Price Index for all urban consumers is the statistical metric developed by the Bureau of Labor Statistics used to monitor the change in the price of a set list of products. Simply, it is an inflation pseudo-tracking device. While not directly measuring inflation, the value gives the Federal Government a good idea of whether the nation is in a period of inflation or deflation and predicts how severe that change may be.

By monitoring the fluctuations in price it costs a consumer to purchase a set basket of goods, the government then uses those number to track the cost of living for person living in those statistically geographical areas. Urban consumers represent approximately 80% of the population in the United States.

Over 200 categories of goods and services purchased for consumption by the population studied are included in the calculations and those 200 categories are arranged into eight major groups that include: Food and Beverages, Housing, Apparel, Transportation, Medical Care, Recreation, Education and Communication and a category called Other Goods and Services (tobacco and smoking products, personal care products and services such as hair care, funeral expenses, etc.)


The MFP or the Multifactor Productivity adjustment measures changes in output per unit of combined inputs. 

How’s that for a government mouthful?

Indices of MFP are produced in the United States for private business, private non-farm business and manufacturing sectors of the economy. The AIF calculation uses the MFP for private non-farm business.

Multifactor productivity measures reflect output per unit of some combined set of inputs. Mutifactor productivity measures reflect the joint effects of many variables including new technologies, economies of scale, managerial skills and changes in the organization of production. In other words, the government is telling us that while they recognize the result of inflation on the ambulance industry, they also believe that we tend to become smarter and work more efficiently too, which offsets the cost of inflation. This means that we really don’t need as many extra dollars as inflation may indicate to balance the books.

Said no EMS administrator anywhere!!!

We’ll Take It!

Of course, we all remember those times of yesteryear when we received four, five and even six percent or better increases from one year to the next. Well those days are long gone.

At least, we see another positive increase unlike two years ago when the AIF fell into the negative range. 

We’ll take it!

Now about those Medicaid fee schedules… ummmm… another time.

Friday, November 17, 2017

Gary's Granola: Fiber for Today's EMS Professionals

Bloggers note- we're featuring a post written by our Quick Med Claims colleague and retired paramedic, Gary Harvat. This week, he reflects on his 40+ year career…

Gary's Granola: Fiber for Today's EMS Professionals
Earthward Bound

A few weeks ago I had the unfortunate experience of plummeting to the ground while on a ladder sixteen feet above the Earth’s surface in my own backyard. I didn’t have much time to think as I fell (it was a quick ride) but I do recall hearing my wife’s voice in the back of my mind stating “You’re going to end up in an ambulance if you keep thinking you can do things you did 30 years ago.” Upon hearing that voice, I tried to make a last ditch grab for the gutter. Sadly, that idea ended in a $50 gutter repair two days later. Fortunately for me, my earthward re-entry ended in a large tree-like bush that broke my fall but not my body. As my son helped me disentangle, I knew I was very close to having my wife’s prophetic words come true. Fortunately, I only suffered some road-rash from the brick on the house and minor abrasions. I was sore for a few days but overall, I was pretty darn fortunate.

With over 40 years in EMS involvement, I have seen my share of roof-plungers and most all of them had significant injuries and sadly, some suffered permanent scars from making the wrong decision about their involvement with ladders, clogged gutters and roof tops.

After I had some time to reflect on my foolish decision, I began to think about that “ambulance thing” that my wife had mentioned. Even though many years of my professional life were spent in the patient compartment of emergency vehicles, the thought of being an actual patient petrified me probably even more than the injuries I might have suffered.

While I no longer work in the field as a line medic, I have evaluated many a young paramedic as they treated patients under my watchful eye. I have seen some great medics and some that are well, you understand. Over the years I’ve watched this industry change and grow. It’s been great with aggressive protocols, drug therapy and field equipment that I only wish I had available to me in the while in the back of that Omaha Orange KKK-A-1822 ambulance.

I’ve noticed that we’ve done a great job at teaching our medics too. They are better trained but have so much more to absorb now than I did 4 decades ago. I honor and respect all of these folks who work this job. They have so much to do and their critical thinking has to be pinpoint.

While the advances have been tremendous, little has been done to address the issue of compassion and personalized attention in the patient compartment. We have worked hard to make sure all that can be done is being done for every patient we encounter. However, along the way we forgot to teach people the importance of looking a patient in the eye and developing a dialogue with them. Have you ever read studies about the importance of holding an older person’s hand? Incredible things happen. The therapeutic effects of human touch cannot be underestimated in the back of an emergency vehicle. While I am not stating that these things are a cure-all for every patient, they do have an incredible calming effect for most.

Today, I watch as many medics try to cram so much into a 15 minute ride to the hospital they forget to even remember the patient’s name. Start the IV, run the meds, adjust the oxygen, monitor the pulse ox, read the EKG and more. The protocols and care we are charged with carrying out seemingly demand so much of us that we don’t have time to even chart our care – let alone converse with our patient.

During my hey-day we didn’t have all of this technology. Sure, we had a 3 lead cardiac monitor and a drug container the size of a Hasbro kiddie’s toolbox. This little box contained the “big meds” we knew as Sodium Bicarbonate, Lidocaine and Atropine. In the 70s, we didn’t have protocols as we had to call for orders and many docs weren’t really sure who we were coming over that squawking box in their ER. As a result, we got a lot of “O2 and transport” for critically ill patients. While these were not orders that changed the save-rate in most cases, it did give us more time to talk with the patient, hold an old woman’s hand or simply carry on light conversation during the ride to the hospital. Don’t get me wrong, I am all for the incredible and positive changes this industry has made in the delivery of pre-hospital care but along the way can we please not forget that these are human beings who are lying beside you? As humans, we like conversation and we genuinely appreciate people who can communicate - even in our worst moments when we as patients may not be so pleasant.

So, after my plunge I began to wonder who would’ve come for me that fateful day. Would I have “La Machine” pre-programmed and trying to cram 10 pounds of treatment into a 5 pound bag or would I have a compassionate human being who put a firm grasp on my shoulder and told me to hang in there during my ride? Or, might I get lucky and have one that did both. I don’t know, it worried me quite a bit and I thought about it a lot after my fall.

My age now dictates the chances of being supine on an ambulance stretcher are much greater than sitting on the squad bench. So, next time you have a roof-plunger or an MI or a broken hip in the second floor rear bedroom, take a moment to remember that the care you deliver is important but don’t forget how equally important eye contact, a firm hand on the shoulder and a caring voice can be. You’ll be pleasantly surprised at the response you will receive.